Provider Demographics
NPI:1124430632
Name:IWANS, JENNIFER ALIDA
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:ALIDA
Last Name:IWANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 CALVIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-2859
Mailing Address - Country:US
Mailing Address - Phone:413-363-3004
Mailing Address - Fax:
Practice Address - Street 1:55 CALVIN ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-2859
Practice Address - Country:US
Practice Address - Phone:413-363-3004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA101Y00000XOtherCOUNSELOR- USE FOR BA STAFF